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Journal of Current Ophthalmology xx (2016) 1e5
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Review

Post-cataract surgery endophthalmitis: Brief literature review

Hesam Hashemian*, Reza Mirshahi, Mehdi Khodaparast, Mahmoud Jabbarvand
Ophthalmology Research Center, Department of Ophthalmology, Tehran University of Medical Sciences, Farabi Eye Hospital, Iran
Received 5 February 2016; revised 11 May 2016; accepted 11 May 2016
Available online ▪ ▪ ▪

Abstract

Purpose: To investigate recent evidence in prophylaxis and management of post-cataract surgery endophthalmitis.
Methods: We conducted a literature search using Pubmed database for post cataract surgery endophthalmitis, and relevant articles were selected
from original English papers published since 2015.
Results: Forty-nine articles were published regarding post-cataract surgery endophthalmitis from January 2015 to February 2016. A low
incidence of post-cataract surgery endophthalmitis has been reported. A growing number of articles are focusing on preventing endophthalmitis
using intracameral antibiotics.
Conclusion: Based on the current evidence, intracameral antibiotics seems to be effective in preventing endophthalmitis after cataract surgery.
Copyright © 2016, Iranian Society of Ophthalmology. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Endophthalmitis; Microbiology; Risk factors; Post cataract surgery endophthalmitis

Introduction
Endophthalmitis, although rare, is one of the most devas-
tating complications of intraocular surgeries. As cataract
surgery consists of a large fraction of ophthalmic operations,
the majority of literature reports about the endophthalmitis is
centered on cataract surgery.1 An aging population worldwide
necessitates an increase in the number of cataract surgeries,
rendering post-cataract surgery endophthalmitis a public
health concern.2
High morbidity and subsequent medical care expenses are
part of this complication.2 Visual outcomes are not often
favorable; about 40% of affected patients sustain severe visual
loss (corrected distance visual acuity of less than 20/200), and
only one-third of cases reach visual acuity of better than 20/
40.3 Evisceration as a last resort has also been employed in the
case of endophthalmitis.4
The reported rate of post-operative endophthalmitis varies
between a range of 0.04%e0.2%.5 However, the incidence of
post cataract surgery endophthalmitis shows significant
changes overtime. By the time of introduction of clear cornea
cataract extraction, as opposed to scleral or limbal incisions,
an increase in endophthalmitis rate was observed.6e8 There
are also studies rejecting this hypothesis, with clear corneal
technique being even a safer approach.9,10

Funding/support: None.
None of the authors has any proprietary/financial interest to disclose.
No conflicting relationship exists for any author.
* Corresponding author. Farabi Hospital, Qazvin Sq., Tehran, Iran. Tel.: þ98
912 680 50 97; fax: þ98 21 55409092.
E-mail addresses: h-hashemian@tums.ac.ir, shhlucky@yahoo.com (H.
Hashemian).
Peer review under responsibility of the Iranian Society of Ophthalmology.
Methods
We reviewed recent literature using Pubmed database to
find original English articles with the keywords “endoph-
thalmitis” and “cataract surgery” or “phacoemulsification”.
The relevant articles for a comprehensive update were selected
with a special focus on those published from January 2015 to
February 2016.

http://dx.doi.org/10.1016/j.joco.2016.05.002
2452-2325/Copyright © 2016, Iranian Society of Ophthalmology. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Hashemian H, et al., Post-cataract surgery endophthalmitis: Brief literature review, Journal of Current Ophthalmology (2016),
http://dx.doi.org/10.1016/j.joco.2016.05.002
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2 H. Hashemian et al. / Journal of Current Ophthalmology xx (2016) 1e5
Results
During the recent year, 49 articles were published on this
subject. Sixteen articles were relevant for discussion in this
review, of which 7 studies were retrospective and 3 of them
were prospective. Also 4 case series, one prospective
comparative interventional cohort study and one cost-
effectiveness analysis were part of included studies. Intra-
cameral antibiotic was the most prevalent subject discussed in
these articles.
Pathogen
Numerous fungal and bacterial agents can cause post-
cataract surgery endophthalmitis, with gram positive,
coagulase-negative Staphylococci being the most common.
Staphylococcus aureus and Streptococcus species are often
identified as causing factors as well.10e13 This observation
reflects the fact that aqueous contamination with surface
bacterial flora is the main event in pathogenesis of endoph-
thalmitis.14 However, gram negative bacteria such as Klebsi-
ella pneumonia may also be encountered occasionally,
especially in Southeast Asia and in the older-age population
based on Lundstrom et al's study.15 Candida albicans is the
most frequently isolated organism in the fungal category.16 In
recent years, Enterococci has emerged as the leading cause,
most likely because of its relative resistance to cefuroxime.3,17
Risk factors
Preoperative risk factors
Many conditions have been postulated as risk factors for the
occurrence of endophthalmitis. Advanced age (>85 years old),
rural residence, male sex, and immunosuppressive states such
as diabetes mellitus are proposed as patient-associated
factors.2,7,8,15,18e20 Performing cataract surgery on the same
day rather than one day after admission may be accompanied
by a higher risk of endophthalmitis.21 In Nam et al's study, the
spring season was an independent risk factor for the devel-
opment of endophthalmitis.22 A systematic review conducted
by Cao et al identified age and male gender as the only pre-
operative risk factors.23
Intraoperative risk factors
Intracapsular and extracapsular cataract surgery, vitreous
loss, and anterior vitrectomy are considered intraoperative risk
factors. Silicone and polymethyl methacrylate (PMMA)
intraocular lens (IOL) optic material compared to acrylic are
associated with higher rates of endophthalmitis. However, the
absence of an injector system for these IOLs and the need for a
larger incision for non foldable PMMA lens can confound this
association.10,19 Based on Weston et al's study at 2015,
injectable IOL is associated with a lower risk of endoph-
thalmitis in comparison with forceps delivered IOL.24 Con-
current eyelid or lacrimal surgery during the same
hospitalization with cataract surgery can increase the risk of
endophthalmitis significantly.25
Please cite this article in press as: Hashemian H, et al., Post-cataract surgery endophthalmitis: Brief literature review, Journal of Current Ophthalmology (2016),
http://dx.doi.org/10.1016/j.joco.2016.05.002
Postoperative risk factors
Limited studies investigated post surgical events affecting
the development of endophthalmitis. A number of risk factors
have been proposed in control cohort and retrospective studies
including starting topical antibiotics the day after surgery
instead of the same day as surgery, not patching following
surgery, and using older generations of fluoroquinolone
antibiotics.26e28
Risk factors associated with postoperative endophthalmitis
based on recent investigations is demonstrated in Table 1.
Prophylaxis
The most important guideline on prophylaxis of endoph-
thalmitis is based on the European Society of Cataract &
Refractive Surgeons (ESCRS) study. This multicenter clinical
trial was conducted on 16,603 patients in 4 arms using peri-
operative topical antibiotic, intracameral cefuroxime, and
placebo.
According to this study, non-use of intracameral antibiotic,
surgical complication, clear cornea incision as opposed to
scleral tunnel, male gender, and implantation of silicon IOL
were associated with a higher risk of endophthalmitis.19
In recent years, prophylaxis against endophthalmitis has
evolved extensively. Suggested preoperative measures include
lid hygiene for reduction of conjunctival flora and meticulous
surgical prep and drape with topical povidoneeiodine.33
Nentwich et al investigated the role of copious irrigation of
periorbital area and conjunctival sac with povidone-iodine in
prevention of endophthalmitis, and based on a 19-year insti-
tutional experience, an 8-fold decrease in the rate of endoph-
thalmitis was observed.34
The beneficial effects of preoperative lash trimming,
saline irrigation, topical antibiotics, and antibiotic-
containing irrigating solutions is not clearly established in
reducing post operative rates of endophthalmitis.10,35e37
However, Sharma et al found that intracameral concentra-
tion of moxifloxacin, whether used topically or orally, is
sufficient enough for the prevention of proliferation of most
bacteria causing endophthalmitis.38 Subconjunctival antibi-
otics can be effective in minimizing the risk of endoph-
thalmitis.10,21 There is growing and compelling evidence
supporting use of Intracameral antibiotic as one of the most
effective countermeasures.2,10,11,39,40 Studies show a 5- to
9-fold decrease in the rate of endophthalmitis via applica-
tion of intracameral cefuroxime.19,41 In addition, the rela-
tive low price of cefuroxime makes it cost-effective in
preventing endophthalmitis.42 Purslow et al also showed
that commercially available intracameral cefuroxime,
Aprokam® costs less than the preparation of cefuroxime in
hospitals.43
However, in 2015, Sharma et al reported the outcome of a
randomized clinical trial regarding the effectiveness of intra-
cameral cefuroxime, and they did not find any statistically
significant additional benefit in preventing endophthalmitis.44
These findings were clinically significant (the rate of
endophthalmitis decreased from 0.155% to 0.108%) and in a
larger sample size, they may be statistically significant as well.
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H. Hashemian et al. / Journal of Current Ophthalmology xx (2016) 1e5 3

Table 1
Summary of recent studies evaluating rate, pathogen, and risk factors associated with post-cataract surgery acute endophthalmitis.
Authors, year [Ref] Country Date Endophthalmitis Pathogen Risk factors
rate
Jabbarvand Iran 2006e2014 0.023% Most cases culture negative Diabetes mellitus, older age
et al, 20152 (63.4%) then (mean age of 81 y), rural patients
Coagulase-negative Vitreous loss, ECCE, surgery on OS
Staphylococci (12.5%)
Lundstrom Sweden 2002e2010 0.035% Staphylococci 31%, Age > 85 y, Vitreous loss, nonuse of
et al, 201515 Enterococci 27% intracameral antibiotic
Nam et al, 201522 Korea 2004e2010 0.037% N/A Age > 80 y and spring season
Du et al, 201429 United States 2006e2011 0.088% N/A Low socioeconomic status, male gender,
age, and use of immunosuppressant
Wu et al, 201430 China 2001e2012 0.17% Staphylococcus epidermidis N/A
(77% of culture positive cases)
Friling et al, 20133 Sweden 2005e2010 0.029% Enterococci (31%) Older age (>85 y), nonuse of
intracameral cefuroxime, vitreous loss
Keay et al, 201220 United States 2003e2004 0.111% for N/A Age (>85 y), male sex, Native
2004 Americans and black patients, less
0.133% for experienced surgeon
2003
Tan et al, 201231 Singapore 1999e2010 0.042% Most cases culture negative Age, male gender, nonuse of
(42.9%) then intracameral cefazolin
Coagulase-negative
Staphylococci
(14.3%)
Das et al, 201132 India 1993e1998 0.13% Staphylococcus epidermidis Ambulatory low socioeconomic
(43.2% of culture positive cases) urban patients
Note: ECCE: Extracapsular cataract extraction. N/A: Not available.

There was a case series of 17 patients with toxic anterior
segment syndrome caused by intracameral cefuroxime,45
which could be attributed to the improper preparation of the
axetil form of the drug.46 Overall, this method of prophylaxis
is safe, and even large doses of cefuroxime are associated only
with transient macular edema and no significant adverse re-
actions.47 In the case of retinal toxicity, visual loss is
reversible.48
Intracameral bolus of cefazolin has also been suggested as a
useful method of prophylaxis.31,49 In a systematic review
conducted by Kessel et al, the quality of evidence was esti-
mated high to moderate in favor of risk reduction attributed to
intracameral use of cefuroxime, cefazolin, and moxifloxacin.37
Adding preoperative topical antibiotic to intracameral
administration of cefuroxime does not seem to produce an
augmented effect in the prevention of endophthalmitis.50
Diagnosis
Endophthalmitis is a clinical diagnosis further supported by
paraclinical tests such as culture of obtained vitreous and B-
Scan ultrasonography.51 Even though approximately 30% of
cases of post-operative endophthalmitis are culture negative,52
isolating the causative organism is the mainstay of treatment.2
This goal is fulfilled by means of aqueous and vitreous sam-
pling as soon as possible, for gram staining, culture, and po-
lymerase chain reaction (PCR) test.53
Management
Intraocular administration of antibiotics is considered the
basic fundamental step in the management of endoph-
thalmitis.54 In order to control massive inflammation caused
by bacterial infection, simultaneous intravitreal injection of
unpreserved dexamethasone is advocated.53 Initially, a broad
spectrum combination of antibiotics such as vancomycin and
ceftazidime or vancomycin and amikacin are injected intra-
vitreally as first- and second-line therapy, respectively.55
Amphotericin B, miconazole, and voriconazole are the drugs
of choice in the case of fungal endophthalmitis.56,57 Intraoc-
ular injections can be repeated at intervals of 48e72 h based
on clinical response.53,58
There is not yet a consensus on whether giving systemic
antibiotic is beneficial or not. Endophthalmitis vitrectomy
study (EVS) found no difference in final visual acuity of pa-
tients receiving systemic antibiotics in comparison with those
who did not.59 However, the European Society for Cataract &
Refractive Surgeons emphasizes administrating adjunctive
systemic antibiotic therapy for management of acute post
operative endophthalmitis.53
Immediate complete pars plana vitrectomy is the gold
standard of treatment of refractory or fulminate acute post
cataract surgery endophthalmitis.53 Similar to draining an
abscess, vitrectomy debrides ocular contents of pus. Obvi-
ously, vitrectomy needs an operation room, in contrast to
intravitreal injection which can be done in an office setting.14
Zhang et al believe that silicon oil tamponade is not necessary
until occurrence of retinal tear or detachment, and IOL
removal is not mandatory primarily.60 EVS results demon-
strate that only patients in a subgroup of initial light
perception-only vision or worse derive a benefit from imme-
diate pars plana vitrectomy.59 However, in cases of rapidly
worsening visual acuity or endophthalmitis caused by virulent
bacteria, immediate vitrectomy is recommended.61

Please cite this article in press as: Hashemian H, et al., Post-cataract surgery endophthalmitis: Brief literature review, Journal of Current Ophthalmology (2016),
http://dx.doi.org/10.1016/j.joco.2016.05.002
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4 H. Hashemian et al. / Journal of Current Ophthalmology xx (2016) 1e5
Visual outcome mainly depends on bacteriology and timing
of treatment with appropriate approaches. Eighty-four percent
of patients with gram positive, coagulase-negative micrococci
endophthalmitis achieve visual acuity of 20/100 or better. On
the other hand, a positive gram stain infection rather than
Staphylococcus epidermidis or gram negative cultures are
associated with a significantly poorer visual outcome. Pre-
senting visual acuity is also a powerful predictor of final visual
outcome.3,62 In Lundstrom et al's study, communication with
vitreous yielded the worst visual outcome.15
Chronic post cataract endophthalmitis
Generally caused by Propionibacterium acnes, this entity
is an indolent form of endophthalmitis usually presented 6
weeks or more after cataract surgery.63,64 The patients typi-
cally complain of moderate pain and decreased visual acuity.
Persistent presence of low level cell and flare in the anterior
chamber is the hallmark of the disease.14 Low-virulence or-
ganism being dormant in posterior capsule has been proposed
as the causative mechanism for chronic endophthalmitis.
Intra vitreal antibiotics, IOL extraction, capsule bag removal,
and vitrectomy are treatment options based on clinical
course.65
Discussion
American Society of Cataract and Refractive Surgery
conducted an online survey from its members in 2014 indi-
cating a growing incline toward the use of intracameral anti-
biotic compared with a 2007 survey, and the major concern
about this method was the low availability of commercially-
prepared formulas for intracameral injection.66
It seems that in recent years, the hottest topic regarding
prophylaxis of endophthalmitis is focused on intraoperative
intracameral antibiotic. Relative safe profile and high efficacy
of this method is observed in many studies; however, more
well-designed randomized clinical trials are needed to confirm
the suitability of intracameral antibiotics. Important questions
such as the antibiotic type, safety profile, and potential com-
plications should be addressed. Based on current evidence,
it seems that intracameral antibiotic at the end of cataract
surgery is an effective approach to reduce the risk of
endophthalmitis.
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http://dx.doi.org/10.1016/j.joco.2016.05.002
5
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